A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?
Contact the client's caregiver to discuss the client's comment.
Review the medical record to see if the client has reported abuse in the past.
Report the suspected abuse to the nurse manager.
Restrict family members from visiting with the client.
The Correct Answer is B
A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.
B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.
C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.
D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.
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Related Questions
Correct Answer is C
Explanation
A. "A nurse discusses a client's postoperative complications during shift report.": This is not a breach of confidentiality if the information is shared within the context of a healthcare team for the purpose of providing care. Confidentiality is maintained as long as the information is shared appropriately.
B. "A facility risk manager includes information from a client's medical record in a when report.": This is also not necessarily a breach of confidentiality if the report is used for quality improvement, risk management, or other institutional purposes where confidentiality protocols are followed.
C. "A nurse tells the chaplain that a client has a new diagnosis of cancer.": This is a breach of confidentiality. Information should only be shared with others involved in the patient's care or if the patient has given explicit consent. Discussing a client's diagnosis with a chaplain or anyone not directly involved in the care plan is an unauthorized disclosure.
D. "A social worker reads a client's chart as a follow-up to a requested consultation.": This is not a breach of confidentiality if the social worker is following established protocols for patient care and is authorized to access the client's medical records for consultation purposes.
Correct Answer is C
Explanation
A. “I will follow a full-liquid diet the day before the procedure.": This is incorrect. Typically, clients are instructed to follow a clear-liquid diet the day before a colonoscopy, not a full-liquid diet. Clear liquids (e.g., water, broth, clear juices) are required to ensure the colon is fully cleaned out for the procedure.
B. “This procedure will take place while I'm under general anesthesia.”: This is incorrect. A colonoscopy is usually performed with moderate sedation or conscious sedation, not general anesthesia. The client may be sedated but will not be completely unconscious.
C. “I have my friend drive me home after the procedure.”: This is correct. After a colonoscopy, the sedation used for the procedure can impair the client's ability to drive. It is recommended that the client arrange for a friend or family member to drive them home.
D. “I can expect rectal bleeding for a week after the procedure.”: This is incorrect. Mild rectal bleeding can occur immediately after the procedure, but it should not last for a week. If bleeding persists beyond a day or two, the client should contact their healthcare provider.
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